Summary: S.837 — 99th Congress (1985-1986)All Information (Except Text)

There is one summary for S.837. Bill summaries are authored by CRS.

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Introduced in Senate (04/02/1985)

Patient and Program Protection Act for Medicare and Medicaid - Amends part A (General Provisions) of title XI of the Social Security Act to direct the Secretary of Health and Human Services to exclude from participation under title XVIII (Medicare) of the Social Security Act any individual or entity: (1) convicted of a criminal offense related to the delivery of items or services under title XVIII or under titles XIX (Medicaid), V (Maternal and Child Health Block Grant), or XX (Block Grants to States for Social Services) of such Act; (2) convicted of a criminal offense, in connection with the delivery of health items or services, relating to fraud or theft, or neglect or abuse of patients; (3) convicted of obstructing any investigation into any offense described above; (4) convicted of unlawfully distributing or prescribing a controlled substance; (5) knowingly and willfully making any false statement in an application for payment under Medicare or a State health care program; or (6) committing certain other prohibited activities.

Authorizes the Secretary to exclude from Medicare participation any individual or entity: (1) whose health care license has been suspended or revoked; (2) suspended or excluded from participation in a Federal or State health care program; (3) submitting false claims under Medicare or a State health care program; (4) where ownership or controlling interest in that entity or a managing employee of that entity is a person who has been convicted of specified health care related crimes, fined for specified health care abuses, or excluded from participation in Medicare or a State health care program; or (5) which fails to supply certain information. Entitles any individual or entity excluded from participation to a hearing.

Directs the Secretary to promptly notify each appropriate State agency administering or supervising the administration of a State health care program of the fact and circumstances of each exclusion. Requires a State to exclude under its programs those individuals or entities excluded by the Secretary, but permits waivers if requested of and approved by the Secretary.

Permits an excluded individual or entity to apply, following the period of exclusion, to the Secretary for reinstatement.

Sets forth provisions providing for civil and criminal penalties for acts involving Medicare or State health care programs abuses.

Prohibits Federal payments with respect to any amount expended for items or services furnished with respect to any individual or entity excluded from Medicare because of the patient and programs protection provisions of part A of title XI.

Requires a State, as a condition of Medicaid plan approval, to provide for the following: (1) a system of reporting any type of adverse action concluded against any health care practitioner or entity by the State or a local licensing authority; and (2) such access to documents as may be necessary by the Secretary. Requires the Secretary to provide suitable safeguards for the confidentiality of such information.

Requires any health care provider providing health care services for which payment may be made under the Act to assure that services or items furnished: (1) will be provided economically and only when, and to the extent, medically necessary; (2) will be quality services which meet professionally recognized standards of health care; and (3) will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing peer review organization in the exercise of its duties and responsibilities.

Permits a State to exclude from Medicaid participation any individual or entity excluded under Medicare pursuant to the patient and program protection provisions. Requires a State in order to receive Federal payments with respect to a health maintenance organization (HMO) to exclude any HMO that: (1) could be excluded because of the conviction of the owners or managers of certain crimes; or (2) contracts with any individual or entity convicted of such crimes. Prohibits Federal payments with respect to any amount expended for items or services furnished with respect to any individual or entity excluded from Medicaid participation because of the patient and program protection provisions.

Prohibits a State under title V from making payments to any individual or entity excluded from participation pursuant to the patient and program protection provisions.

Revises disclosure requirements under part A of title XI. Revises Medicare provisions concerning agreements with providers.

Sets forth effective date provisions.

Amends the Controlled Substances Act and part A (General Provisions) of title XI to authorize the Attorney General to suspend or revoke a registration to manufacture, distribute, or dispense a controlled substance upon a finding that the registrant has been excluded from participation under the Medicare program.